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Thursday, 28 April 2011

Visit To BOSPA- British Obesity Surgery Association

Yesterday I did a talk at a self help group for bariatric (obesity surgery) patients in Chsiwick. My talk was called "What is normal eating anyway?" I guess I should be blogging about this sooner or later.

There were some pre-ops there wating for surgery or just getting some information and some post-ops talking about their experiences. The common theme from the post-ops was that the surgery had changed their lives; they were walking miles and wearing clothes that had been in the attics for years. The gastric banders were certainly less successful and the gastric sleevers and the gastric bypassers were equally happy.

Now for many of them it is early days and as time goes by they have to confront some obstacles. I was so sad that there aren't many people with the wisdom and training to help them emotionally speaking. One soul was angry with me for being there talking to them in my slim body, she felt that I would have no idea at all what she was going through. She is a deeply compulsive eater who ate 20 easter eggs over the last weekend and she has been refused surgery until she has "dealt with her eating disorder" but how is she supposed to do that?

Everyone is talking about "getting CBT" or she has "had CBT" and it didn't work. But CBT does not work for everyone, if that is all the therapist is doing - there is only 50% success rate with CBT alone. So, we need to take each person, one at a time and bring a whole range of skills to the table which can be built around a package of treatment that will focus on the eating disorder mindset at its heart but can also provide help with feelings, trauma, lifestyle and empowerment.

Don't you think? Email me if you have a view on this - see above and remember to visit our website www.eating-disorders.org.uk to see what is going on.

Thursday, 21 April 2011

Top Tips For Working With Eating Disorders: Counsellors Must Get Anxious Too

I wrote a few days ago that clients must be a little and sometimes a lot anxious for therapy to work. We therapists must be able to tolerate our own anxiety too.

My own experience mentoring therapists is that can get very anxious. Someone may be losing a lot of weight and nothing the therapist does seems to stop this from happening. Someone with bulimia may be reporting very frequent purging. Someone with anorexia is gaining a little weight and then there is a setback; weight goes down, someone seems to “stop trying”.
Or a person with a weight problem is doing very well. The therapist is anxious, can she keep it up? The client seems to be a little less motivated; is she heading for a relapse?

Carers’helplessness can make a therapist very anxious too. The carer come to us saying “This therapy isn’t working! My son/daughter won’t talk to me! Why aren’t you able to stop her or him from losing weight now!”

Or maybe our client tells us that their parents seem to be at war with each other. Why has a parent bought their anorexic child a gym club membership for Xmas? What on earth is going on?

Therapists can get very anxious because they simply do not know what to do next with someone who seems to be very stuck; we start off by considering ourselves as the client’s white knight and then we start thinking of ourselves as a bad therapist. None of this anxiety is going to help the client in the end.

One way of preventing anxiety is to suspend any emotional interest in recovery, weight loss - or even weight gain if it comes to that. This surprises people. Surely is it natural for us to praise the anorexic who gains weight and to praise the obese person who loses it? The whole slimming industry is based around rewarding people for weight loss - with gold stars, medals and badges of honour. We pat anorexics on the back for weight gain, which they hate - and only confirms to them that they might be getting fat.

And surely it is useful for us to want our people to recover? Yes, but we must have personal investment in this. Our clients must want it – not us! So we must simply be willing to stay beside them on this journey. While praise and criticism may work a little in the short term, it hardly helps in the long term. By rewarding weight, for example, we are rewarding the wrong thing – people are not always happy if you reward weight change because you are not rewarding what really counts, their efforts, or their willingness to learn new things. You are simply teaching them to look to you for praise and to be scared of your disapproval if they fail. This is hardly good practice and it does not teach people how to motivate themselves when the going gets tough.

This kind of struggle for position with a therapist was well described in a recent conversation with a therapist who had this to say about her anorexic client:

“The Client made me feel like I wanted to rescue her and not be yet another person who let her down. This level of anxiety required containment as was achieved through the establishment of a relationship that was one of listener yet provider of education, settler of tasks and presenter of hope.”

The therapist needs to deal with the fear of letting the client down because sometimes our clients come with impossible expectations of therapy and a therapist that can never be met. It is clear that therapists can be neither to be the white knight nor the abuser. If we focus too much on being good enough for our clients we may miss what the disorder is communicating about our client and their motivations.

By the same token it isn’t really helpful to get anxious if weight falls during recovery from anorexia. It could just be a blip and we need to wait and see before getting in to a panic. Weight does not always follow a straight line and it is better to wait and see what is really going on. If I am working with someone whose weight is truly falling week by week, I tend to stay calm as a cucumber. I would say “the Voice seems to be shouting at you at the moment. What do you feel you would like to say to it?”If weight is going really low, I might say something like this “It seems to me that one way of taking care of yourself is to get so weak that you will have to go to hospital. Another way of taking care of yourself could be to eat a little more. I wonder which of those feels best for you.”

So we therapists need to be able to tolerate uncertainty (Waller 2010 CBT Today) without panicking. If we are worried about the weight of a client we are not able to focus on what the undesired change is telling us. It is much harder to be half way recovered from anorexia than it is to be in denial about how unwell you are. You may have gained weight, but you will have lost everything that the disorder did for you without feeling any of the benefits - yet.

If someone seems to be stuck, there are many reasons why this is so. Taking supervision is a very good idea of course and sometimes you may have to consider putting therapy on hold. You can say “We have come as far as we can – for now”.

And if someone fails with yet another weight loss plan you are coaching them in - it could be that you are not in touch with everything they believe is bad about weight loss. One obese person confessed to me that he felt that people who don’t let themselves overeat at holiday times “are boring”. Why would he want to be like that? The therapist panics and misses the opportunity to listen to what the client has to say.

An anxious therapist is one who gets easily angry and into blaming mode: they aren’t trying; they aren’t ready: they are rebellious and naughty. This therapist is not resourced and will not serve their client well. If I am mentoring an anxious therapist I will turn my attention to the therapist’s anxiety rather than the client’s apparently difficult behaviour. What does this anxiety remind you of? What are your beliefs about uncertainty?

Calm down and let the bad ideas go, and maybe something inspirational will come to you both. From ”sufferers” out there in the community, some with long standing problems and some just newly captured by an eating disorder, I hear a lot of bad things about therapists who get angry and abusive, who give people clearly inappropriate treatment, or unwelcome labels without thinking what they are saying or what that will mean, who haven’t listened, or who simply do not speak the unique language of an eating disorder. How can any eating disorder therapist fail to understand the Voice? Most of this boils down to anxiety. We all need to be able to tolerate anxiety without panicking.

Tuesday, 12 April 2011

Having An Eating Disorder: What Does It Mean About You?

Melanie Reid who writes about her spinal injury in The Times says; … the world is split into people who moan and people who don’t. I have heard enough moaning in the past 12 months to last me a lifetime. In this regard, I refuse, ever again, to spend time with anyone who complains continually about the weather, their job, their relationship or their appearance. These people are death to the soul; they suck the oxygen out of the air; they need to be avoided at all costs. …….. avoid people too stupid to appreciate what they’ve got. Like loud and aggressive persons, they are vexations to the spirit.

So, are people with anorexia or bulimia stupid?
Or, vexations to the spirit?

On television recently I said words to this effect. People with anorexia are sensitive, even before the illness they find it hard to cope with the slings and arrows of life. And this brought forth a sort of rant from someone, let’s call her Jane. She said to me, you are saying that anorexics are weak, you are undoing all the good I am trying to do trying to get people to understand this illness! I work as an Ambassador for B-eat and you are undoing all my good work!!! My reply to her was lengthy.

So, are people with anorexia or bulimia weak?

And, in OK magazine this week, there is a story of a footballer’s wife who is fading away and refusing to eat, having got rid of some baby weight plus a great deal more. She admits to having anorexia and who knows what else she is doing to herself. She threatens, if anyone comments about my weight loss I will stop eating even more. Now here’s the thing; mature people do not punish people who reach out to show their love, do they? If someone says to me “You look tired, are you working too hard” I say to them “Thank you for caring”. Her anxious friends are damned if they show their concern and they are damned if they don’t.

So, are people with eating disorders infantile or immature?

One person who wrote to me recently said her therapist views her as having a “mental health problem”. Another therapist suggests that she suffers from “Body Dysmorphic Disorder. Because of the shame she feels about these unwelcome labels she is unable to continue with treatment. She chooses to wake up every day trapped in the prison of her eating disorder and her preoccupations with food and weight, rather than be labelled as a mental case.

So, are people with eating disorders mentally ill?

An eating disorder charity says “it’s not about food, it is about feelings”. I heard myself say this on ITV as well. We talk of using food or starving to medicate pain or block feelings that cannot be expressed. I have found that some of my people seem to have “too many feelings” and use binge eating or purging just to calm themselves down. Purging can be the only way you know to get those feelings out.

So, are people with eating disorders “in pain”?

Experts who write textbooks for each other say all kinds of things about people with eating disorders and call it “research findings”. They associate eating disorders with many different pathological presentations. If we are to believe this research, we would view people with anorexia, bulimia and compulsive eating as being either:



Personality disordered?

Narcissistic – desperate for attention and desperate when they don’t have it in the way they want?

Dependent- always needing approval from other people?


Insecurely attached; meaning not very good with relating to other people?

Having autonomy fears - which means that they aren’t able to grow up, separate from their families and live “normal lives”?

Experts, even those with eating disorders themselves, pre suppose that there is something very wrong with eating disorder sufferers and bend over backwards to be kind and do everything they can to help the person with self esteem. Even in the field of obesity work, there are experts who designate all emotional eaters as food addicts with poor attachment skills.

And experts do not generally view the person with an eating disorder as very strong, no matter how much they can manage hunger pangs. We call this perfectionism, which is always couched in derogatory terms. We may secretly wish that someone could simply lighten up.

And, that feels to me like a slap in the face with a wet kipper too.

Or are people with eating disorders amazing, strong, creative, intelligent people who have been captured by an evil spirit? It sometimes feels like that to people looking on. If that were so we would have to accept that someone with an eating disorder is enslaved.

When I see someone with an eating disorder, whether it is anorexia, bulimia or binge eating disorder, I try not to make assumptions about what is wrong or right about them. Yet it is hard not to see predictable patterns in each disorder. Our sufferers are generally misinformed about food, dieting and weight. They know a lot about calories but very little about the science behind appetite and weight control. As to the rest, there is a great deal of fear, panic and anxiety. Closely followed by shame, misery and guilt. There is a huge amount of self talk about food, weight and diets. There may be a great deal of purpose in managing food but very little self confidence, something which we all aspire to in life.

There is a trail of people in the wake of the sufferer who are confused, angry or worried. Eating, it seems, is a relational issue. So the collateral damage of an eating disorder is very far and wide.

So what does it mean about you if you have an eating disorder? I say this. Stop worrying about the labels for a start, because these labels do not capture what it means to be human and imperfect. I am not sure that we can quest for recovery, or even desire it, until we have looked inside ourselves to find out “what my eating disorder is saying about me, personally”.

Perhaps we all need to accept our shadow side, name the bad as well as the good, the weak with the strong, the evil and the angelic, so that we can become the master of our fate.

Friday, 8 April 2011

Denial in Bulimia Nervosa

It’s normal to want to be in control over our eating habits. It’s normal for some people to want to let go of that control some of the time like at Christmas time or when you are having a picnic with friends. It’s very normal for some people to eat a horribly bad diet full of junk food, because they like the taste. Perhaps they think that people who eat healthy food are boring? I often wonder if they are in denial about how dangerous their eating habits really are, when they tuck into their ready processed trans-fatty laden foods. But who am I to judge? If we all ate what is best for us, the economy would collapse. Who would be left to buy chocolate flavoured coco pops or one kilo chocolate bars?

On the other hand, since I have just written a blog about Orthorexia which invited some dissention, I wonder how many healthy eaters out there are in denial about the emotional issues that are behind their dietary rules. When it comes to food, we do the best we can with the resources we have at the time.

So, there is lots of denial around and so what, anyway. Experts say that where bulimia is concerned, denial isn’t really an issue because sufferers are already fully aware that their control over eating has been undermined. They know that they have a problem, and they know that normal people don’t do what they are doing -which is why they take such trouble to hide their rituals. I guess that last sentence doesn’t apply to Jockeys – where purging is normal, or models who teach each other all the tricks for staying thin so that they won’t be accused of looking fat.

People in the early stages of bulimia may be in denial about their behaviour. They don’t yet know it has a name. They almost certainly don’t know that what starts as a way of controlling weight gain quickly becomes an addiction. In the beginning, it is something they control and it ends up controlling them. They never know when they will think they have eaten one bite too many and will have to get rid of it as soon as they can. They certainly don’t know that what begins as a way of controlling food turns into a way of managing feelings. They are denial about their ability to stop.

They also deny to other people that they are doing anything unusual and go to a great deal of trouble to cover things up. Spraying perfume in the bathroom or playing the radio to mask the sounds of purging are common tactics. Pretending to your boss that you have a stomach upset is better than saying you have taken too many laxatives. This makes sense; few of us would want to admit to doing things that would cause us shame.

Denial has a lot of different meanings. People can think that what they are doing is okay because they lack the information which would help them to think differently. Many people who vomit or take laxatives think that this is a really good way to control their weight and they are therefore terrified to stop. Purging is a wonderful weight gain strategy in the long run and many bulimics gain a great deal of weight. This is because purging affects the appetite chemistry of the brain and purging interferes with the body’s ability to burn off calories.

The word “denial” implies, however, that even with the right information people say “this doesn’t apply to me” or “I don’t believe it” or “what I am doing now is better than any alternative that comes to mind” or “I don’t have a problem and can stop whenever I like”.

Perhaps the most interesting form of denial is to say “I know I have a problem but I am not sure I want to do something about it”. Therapists call this “ambivalence” and they are anxious to turn this into a real desire to change. We can understand ambivalence by turning our attention to the benefits of having an eating disorder. For one thing, purging allows us to have what we like without having to pay for it, to have our cake and eat it, so to speak. Taking laxatives helps get rid of everything that feels bad and dangerous and that mustn’t stay inside.

Bingeing and purging isn’t just a way of getting rid of food, it gets rid of feelings as well, and it helps us to get on with our day. I have often thought that purging is a kind of communication. It says what someone is unable to say, such as “I hurt, I am angry, I feel confused, I can’t cope with this, I hate you because you are more popular than me”.

And people can also be very ambivalent about change because they aren’t convinced that their problem is all that serious. One person put it like this:
“I found that - the part about me having a very serious eating disorder - hard to listen to ..because I physically look totally fine so I have been saying if it were that serious then I would surely look as if I have one when I don't and ….eating disorders are mental health conditions so if they are right and I do have a serious case of bulimia then I actually have a mental health condition and I feel really uncomfortable about that…”

So here we have two aspects of denial, one about whether the problem is serious enough and one about being willing to accept what the bulimia might mean about you.

Regarding seriousness, let’s make no mistake. Bulimia is not just about getting rid of food. Everything is affected, your brain, your fertility, the cells in the throat and mouth, the damage to the gut. Blood tests tell us very little about what is changing in our cells so it may be years before the damage shows up. It’s much the same as smoking. You can live a long life with bulimia – of course, but I doubt it will make you very happy. I don’t call to health risks to persuade people to change. On the other hand, bulimia makes you gain weight very easily and that does make people with bulimia very uneasy.

If you want to deny the seriousness of bulimia in case it means you have a mental health disorder, take heart that some bulimics DON'T have serious mental health problems. And some normal eaters DO have mental health problems so why bother to get into a strop about labels. I will have to another blog about that!

An eating disorder - whether you think it serious or not - is something that stops us from having to pay attention to what isn’t working underneath. It’s easier to think that you have an eating problem which isn’t really going to do you much harm, than it is to grapple with a problem that is really painful. Many bulimics have had a history of serious invalidations, unhappy childhoods, struggles coping with an alcoholic parent or abuse from other people which they were powerless to prevent.

For these reasons, I do not fight against denial nor do I assume that my enthusiasm for recovery will be taken up by my clients. Some people have been upset with me for so-called labelling people as bulimics, anorexics or orthorexics. At the end of the day it is about people, not about labels and it's about figuring out how to help someone to be happier. I know that purging, starving and binge eating helps someone feel safe but isn’t a recipe for a happy life; it is happiness and a meaningful life that is always in my focus.

Thursday, 7 April 2011

Criteria For Recovery From Eating Disorders A Reader Request

Someone has asked me if there is a definition for recovery. What do you think recovery means? What does it mean to you? Recovery to me meant that eating did not rule my life. Many people think that recovery is about gaining weight if you are anorexic or stopping symptoms like vomiting or taking laxatives. The good therapist knows that recovery is much more about the person than their weight or their eating disorder symptoms. Recovery is helping a person to reclaim what has been surrendered to the illness. This means finding their potential, their trust, their sense of safety, their ambition or purpose and their ability to manage their feelings and connect properly with other people. But the following can do for a start.

Does not take laxatives
Is able to express their emotions (verbally)
Does not feel too fat
Self esteem is no longer dependent on weight
Does not punish herself after a meal
Has a realistic image of herself
Can eat three meals a day
Has no binges
Does not vomit after dinner
Does not use diuretics
Is not obsessed by food and weight
Is able to express emotions (non-verbal)
Is able to handle negative emotions
Is not isolated
Feels no need to slim excessively
Does not exercise excessively
Does not use slimming pills
Accepts appearance
Is in touch with their own feelings
Has a positive experience of their body
Has adequate self-esteem
Is able to handle positive emotions
Is not depressed
Amount of calories is normal
Heartbeat is normal
Is able to handle conflicts
Sleeps normally
Is able to make contact with others
Has some friends
Is not extremely perfectionistic
Dares to express a different opinion

Finally, recovery is when the person can accept his or her natural body size and shape and no longer has a self destructive or unnatural relationship with food or exercise. When you are recovered, you do not use eating disorder behaviours to deal with, distract from, or cope with other problems. When recovered, you will not compromise your health or betray your soul to look a certain way, wear a certain size or reach a certain number on the scales.